Wednesday, June 24, 2009

President Obama's Prescription for America Pacemaker Question

The Disease Management Care Blog just finished watching ABC News Primetime's Prescription for America. It is impressed. With all the things Presidents do plus worrying about financial reform, turmoil in Iran, missles in Korea and the split between John and Kate, Mr. Obama did a remarkable job of navigating around all the issues without any major gaffes.

However, he stumbled over the pacemaker question from Jane Sturm. Recall she's the woman with the centenarian mother who was the exception to the rule that expenses - like '$30,000' pacemakers - are needlessly wasted on persons in their last year of life. The good news for momma Sturm is that she is doing well enough to sit outside and chat with her daughter in the summer sun 5 years later, even if she is wearing a transcendentally false wig. Jane was afraid that Mr. Obama was promoting a health care system that would withhold such life saving treatment in the face of someone still having a certain spirit and a quality of life.

Mr. Obama didn't really deny it. The DMCB can't find a transcript of the encounter yet, but the President vaguely discussed the need to rationalize end of life care and specifically said that judgments based on 'spirit' would be too 'subjective.' There was also a nod to the decision-making being something best left to doctors and patients.

First, some background. A pacemaker is a battery powered device that is placed under the skin next to the collarbone. Under that area is a large vein. It is through that vein that one or more wires from the pacemaker is threaded, which follow the course of the vein toward the heart. The end of that wire is stuck into the inside of the heart muscle. An intermittent current goes from the pacemaker pack through the wire and mildly stimulates/shocks the heart muscle in a regular basis that causes it to contract. If the heart muscle is beating too slow because the normal signals that intrinsically govern the heart rhythm are disordered, the pacemaker can override the problem with the electric shocks that cause the heart to contract on a more regular basis. Pacers can also treat other types of rhythm disturbances including fibrillation (that type is pictured above). Heart rhythm problems are common among the elderly and pacemakers can make the difference between a person prone to regularly passing out, falling or being dizzy versus a person that is able to lead a normal life. There are many different types of pacemakers

It turns out that evidence-based guidelines are readily available to physicians who are considering a pacemaker. The DMCB looked at the document and cannot find any statement that supports the notion that age is a sole criterion on the decision to put in a pacemaker. In fact, there is one statement (about one type of pacer device) that says 'although survival after implantation is shorter among the elderly than among younger groups, survival is substantial, and age itself should not be the predominant consideration in the use of device-based therapy among the elderly' (italics from the DMCB). That being said, there is evidence that pacemakers can be overutilized.

The DMCB....

1. ...thinks it's difficult for a layperson, even if he is a President, to navigate around the thorny complicated medical issue of putting in this kind of hardware in the elderly. He intuitively understood that saying that all Americans should never be denied a pacer would have been silly, but he also understood that saying always withholding pricey therapy in 100 year olds was also risky. He sought out a more nuanced answer and eventually landed on the doctor-patient relationship as the final element in the decision-making process. The DMCB suspects critics on both sides of the issue will be able to use the President's answer against him.

2. ...speculates, given the circumstances, that it was a physician who declined to OK the pacemaker and that the family decided to seek out a second opinion. The insurance company (and it was probably Medicare) played no role in the decision making process. The ready availability of guidelines should make this a non-issue because medical directors and practicing physicians would rarely if ever disagree here. Unlike 'life-saving' vs. 'experimental' or 'futile' cancer therapy battles, it is unlikely a 'denied pacemaker treatment' will even spill over into the evening news involving Medicare, a commerical insurer or a even public option plan.

3. ...points out, last but not least, the 'system' worked, didn't it? The pacer was initially denied, the patient's family appealed and they eventually prevailed. Mr. Obama has pointed out that there are areas in the health care system that work well. He has repeatedly stated that he wants to keep what is right and fix what is wrong. Well, this is one area that turned out right. Mrs. Sturm need not worry about it and the President can confidently know that there is evidence that can govern this part of the healthcare system where ageism isn't an issue.

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About Jaan Sidorov MD, MHSA, FACP

has the web persona of a blogvocateur with a wide range of knowledge about the medical home, disease management, population-based health care and managed care that is only exceeded by his modesty. He has been quoted by the Wall Street Journal, Consumer Reports and NPR’s All Things Considered.
He has over 20 years experience in primary care, disease management and population based care coordination. He is a primary care general internist and former Medical Director at Geisinger Health Plan. He's a widely sought after speaker too.
He is primary care by training, managed care by experience and population-based care strategies by disposition.
The contents of this blog reflect only the opinions of Sidorov and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic. This is also not intended to function as medical advice. If you really need that, work with a personal physician or call 911 for crying out loud.
Jaan can be reached at jaansATaolDOTcom.